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Based on medical record review, staff interviews, and policy reviews, the facility failed to ensure patients received enteral feedings as ordered and patients received assistance with turning and repositioning to prevent skin injuries.

See A392.

Based on record review, interview and policy review, the facility failed to ensure patients received enteral feedings as ordered and failed to ensure patients received assistance with turning and repositioning to prevent skin injuries. This affected one (Patient #6) of ten patients reviewed.

Findings include:

1. Review of the medical record for Patient #6 revealed the patient was transferred from an acute hospital on 11/13/23 at 5:31 PM with a diagnosis of acute hypoxic respiratory failure. According to the attending physician's history and physical, the patient was admitted for ventilator weaning and rehabilitation. The patient was admitted to an acute hospital after experiencing cardiac arrest in the field without a bystander resulting in severe hypoxic ischemic encephalopathy. Patient #6 was status post tracheostomy and percutaneous endoscopic gastrostomy placement.

Review of the medical record revealed Patient #6 had physician orders for continuous tube feedings including: 11/13/2023 at 7:01 P.M., Diabetisource AC (Glucerna 1.2) full strength at initial rate of 30 ml per hour per Percutaneous Endoscopic Gastronomy (PEG) tube, increase 15 ml per shift until target rate of 60 ml per hour is met; 11/14/2023 at 1:51 P.M., Diabetisource AC (Glucerna 1.2) target rate 60 ml per hour per PEG tube, increase 25 ml per 12 hours to target rate/ 1320 ml total Tube Feed (TF) volume per day; 11/27/2023 at 10:17 A.M., Diabetisource AC (Glucerna 1.2) 60 ml per hour per PEG tube for 1320 ml total TF volume per day; and 12/15/2023 at 3:15 P.M., Diabetisource AC (Glucerna 1.2) 65 ml per hour per PEG tube for 1320 total TF volume per day.

Review of progress note dated 11/20/2023 at 3:36 P.M. Registered Dietitian (RD) M documented Patient #6 only received 80 percent of total volume TF in the past 72 hours. On 11/28/2023 at 3:50 P.M. RD M documented Patient # 6 only received 81 percent of total volume tube feeds in the past 72 hours. On 12/06/2023 at 3:38 P.M. RD M documented Patient #6 was tolerating TF at goal rate and only received 84 percent total volume of TF in the past 72 hours. On 12/13/2023 at 3:16 P.M. RD M documented Patient #6 was tolerating TF at goal rate and had only received 87 percent goal volume in the past 72 hour. Additionally, RD M noted Patient #6 was consistently not receiving goal TF volumes and increased the rate to 65 ml per hour.

Review of flow sheets dated 11/14/2023 to 12/21/2023 revealed Patient #6 received 100 percent of the daily goal of 1320 ml TF volume per day 10 out of 38 days. Further review revealed 19 of 38 total daily TF volumes were less than 80 percent of the daily total volume goal of 1320 ml TF per day.

During an interview on 02/22/2024 at 10:17 A.M. RD M stated she retrieved total daily TF volumes directly from the patient's pump and documented them in the patient record. If a patient was receiving an oral diet in addition to tube feeding, the Dietitian was satisfied adequate nutrition was achieved if the patient were receiving at least 75 percent of daily goals for tube feed volume. If a patient's only source of nutrition was from tube feedings, the dietitian stated they expected to see the patient receive 90 percent or greater of daily TF volumes. RD M stated she had noticed a pattern that Patient #6 was only receiving between 80 to 90 percent of her total volumes of tube feeding. RD M was aware the family were concerned the TF was turned off frequently when they visited. RD M verified when she checked the pump, Patient #6 was consistently getting less than 90 percent of her total daily TF volumes and spoke with Patient #6's family about it. The new plan of care included increasing the rate from 60 ml per hour to 65 ml per hour. RD M stated the patient was discharged before she was able to follow up after the hourly rate was increased.

Review of policy titled "Enteral Nutrition" dated 02/01/2006 revealed PCA's and Therapists could activate the "HOLD" function of the feeding pump for activities whenever the head of bed was lowered less than 30 degrees. The nurse was notified when feeding was held and the nurse was responsible for disconnecting the tube, reconnecting the tube, and re-initiating feeding.





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2. Review of a physician order on 11/14/23 instructed staff to turn and reposition Patient #6 every two hours.

The Daily Cares/Safety Flow sheet from the patient's admission on 11/13/23 to discharge on 12/21/23 was reviewed for staff turning and repositioning the patient. Documentation of staff turning and repositioning the patient every two hours was noted from 11/13/23 at 8:00 PM to 11/18/23 at 11:00 AM. The flow sheet revealed that the patient was turned and placed in a semi-fowler's position on 11/18/23 at 11:00 AM. At 12:15 PM, 1:00 PM, 2:20 PM, 3:00 PM, 4:45 PM, and 6:00 PM, the patient remained in a semi-fowler position. At 8:00 PM, pillow support was added to the patient's semi-fowler position. The flow sheet was reviewed with Staff O on 02/22/24 at 10:30 AM. It was confirmed that eight hours elapsed with the patient in a semi-fowler position. It was also confirmed that semi-fowler is a supine position in which the patient is on their back on a bed with the head of the bed elevated between 30-45 degrees. On 11/20/23 at 6:00 PM, the patient's position was changed from lying on the right side to a semi-fowler position with pillow support. At 8:00 PM, 9:00 PM, 10:00 PM, and 12:00 AM on 11/21/23, she remained in a semi-fowler position with pillow support. It was confirmed that the medical record lacked documentation the patient was turned for six hours. Further review of the flow sheet revealed on 11/28/23 from 10:00 AM to 2:00 PM, for five hours, the patient was positioned on her right side. The patient was repositioned to her left side at 3:00 PM. On 12/06/23 at 7:00 AM, the patient was positioned to a semi-fowler position. At 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, and 8:00 PM, she remained positioned in a semi-fowler position. Staff O confirmed that the patient remained in a semi-fowler position on her back for more than 10 hours. On 12/09/23 at 5:00 AM, the patient was positioned in a semi-fowler position where she remained until 8:00 AM. On 12/11/23 at 12:00 PM, the patient was repositioned from her right side at 10:00 AM to a semi-fowler position with pillow support. According to the flow sheet, the patient remained in a semi-fowler position until 8:01 PM, approximately eight hours. On 12/14/23 at 5:00 AM, the patient was repositioned to her left side where she remained until 9:00 PM, approximately 16 hours. On 12/16/23 from 2:00 PM to 10:00 PM, the patient was noted to be positioned on her right side. It was confirmed that the patient was not turned and repositioned for approximately eight hours. On 12/20/23 at 7:00 AM, the patient was re-positioned to a semi-fowler position. She remained in this position until 8:00 PM when pillow support was added. At 7:00 AM on 12/21/23, the patient was positioned to a semi-fowler position where she remained until discharge at 12:18 PM.

The facility policy titled Inpatient Nursing Documentation for the Permanent Medical Record, effective 07/19/18, was reviewed on 02/22/24 at 12:45 PM. According to the policy, nurses and patient care assistants are instructed to turn and reposition every two hours during safety rounds.

Staff O and Staff D were interviewed on 02/22/24 at 1:00 PM. It was confirmed that the medical record lacked documentation the patient was turned every two hours as ordered.